Emergency Medicine literature of Note - Posted by Ryan Radecki - June 29, 2015
“Clinical Policy: Use of Intravenous Tissue Plasminogen Activator for the Management of Acute Ischemic Stroke in the Emergency Department” - Approved by the ACEP Board, June 24, 2015
The highlights:
- The Level A suggestion to consider the risk of ICH with tPA administration has been eliminated. It has been moved, nonsensically into the Level B recommendations for offering tPA – when, frankly, it’s the only consistent finding across all the evidence.
- The Level B recommendation in which tPA “may be given” within 3 hours has been strengthened to “should be offered and may be given”. Obviously, a profound difference.
- The Level B recommendation for 3-4.5 hours remains unchanged, based on only one flawed piece of Class II evidence (ECASS III), and conflicting Class III evidence (ATLANTIS, IST-3, meta-analyses).
- The Level C recommendation to engage in shared decision-making now states “when feasible”, which is obviously open to interpretation.
- No further clarification of “carefully selected patients” or “systems … in place to safely administer the medication” is provided.
http://www.emlitofnote.com/2015/06/the-new-improved-acep-clinical-policy.html